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Which intervention is most important for the nurse to implement for the client with a left nephrectomy?
- A. Assess the intravenous fluids for rate and volume.
- B. Change surgical dressing every day at the same time.
- C. Monitor the client’s PT/PTT/INR level daily.
- D. Monitor the percentage of each meal eaten.
Correct Answer: A
Rationale: Post-nephrectomy, maintaining adequate hydration and perfusion to the remaining kidney is critical to prevent acute kidney injury. Assessing IV fluid rate and volume ensures proper fluid balance. Dressing changes, coagulation monitoring, and meal intake are less urgent.
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Which finding provides the best evidence that peritoneal dialysis is achieving a therapeutic effect?
- A. Urine output increases.
- B. Appetite improves.
- C. Red blood cell count is lower.
Correct Answer: B
Rationale: Improved appetite indicates reduced uremia, a sign that dialysis is effectively removing toxins.
To avoid erroneous test results caused by the manipulation of the prostate, the nurse should be included in diagnostic test before the client's rectal examination?
- A. Kidneys, ureters, bladder X-ray
- B. Needle biopsy of the prostate gland
- C. Prostate specific antigen (PSA) test
- D. Transrectal ultrasound examination
Correct Answer: C
Rationale: The PSA test should be done before rectal examination, as manipulation can elevate PSA levels, leading to false results.
The client diagnosed with renal calculi is scheduled for lithotripsy. Which postprocedure nursing task is the most appropriate to delegate to the UAP?
- A. Monitor the amount, color, and consistency of urine output.
- B. Teach the client about care of the indwelling Foley catheter.
- C. Assist the client to the car when being discharged home.
- D. Take the client’s postprocedural vital signs.
Correct Answer: C
Rationale: Assisting the client to the car is a non-clinical task within the UAP’s scope. Monitoring urine, teaching catheter care, and taking vital signs require nursing judgment and are not delegable.
The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care? Select all that apply.
- A. Monitor vital signs every two (2) hours until stable.
- B. Monitor the client’s oral intake and urinary output daily.
- C. Administer mouth care when bathing the client.
- D. Weigh the client weekly in the same clothing at the same time.
- E. Assess skin turgor and mucous membranes every shift.
Correct Answer: A,B,E
Rationale: For fluid volume deficit, monitor vital signs frequently for stability, track intake/output daily to assess hydration, and assess skin turgor/mucous membranes for dehydration. Weekly weights are too infrequent, and mouth care during bathing is not specific.
The nurse identifies the concepts of elimination and immunity for a female client diagnosing with a urinary tract infection. Which discharge instructions should the nurse provide the client? Select all that apply.
- A. Teach the client to wipe from front to back after voiding.
- B. Encourage the client to drink cranberry juice each morning.
- C. Inform the client that frequent episodes of incontinence are expected.
- D. Discuss the signs and symptoms of a recurrent infection.
- E. Have the client fill a container of water to sip until at least 2,000 mL is consumed.
- F. Request that the client sit in a tub of warm water twice a day for 25 minutes.
Correct Answer: A,B,D,E
Rationale: Wiping front to back prevents bacterial spread, cranberry juice may reduce UTI risk, discussing recurrent symptoms aids early detection, and 2,000 mL fluid intake flushes the bladder. Incontinence is not expected, and tub baths increase infection risk.